16B-028 1 _ � BP- 2010 -0080
GIS #: COMMONWEALTH OF MASSACHUSETTS
. 028 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cat BUILDING PERMIT
Permit # BP- 2010 -0080
Project # JS- 2010 - 000086
Est. Cost: $1865.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME DEPOT AT HOME SERVICES
Lot Size(sq. ft.): 10018.80 Owner: O'SHEA DANIEL K
Zoning URB( 100) Applicant: HOME DEPOT AT HOME SERVICES
AT. 1 BEECH ST
Applicant Address: Phone: Insurance:
345 GREENWOOD ST (401) 935 -2633 0
WORCESTERMA01607 ISSUED ON. 712212009 0:00:00
TO PERFORM THE FOLLOWING WORK.- Door
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 7/22/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
t
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit' -
212 Main Street Sewer /Septic Availability �'-
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/SitIe Plans
Other Specify -
[ APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
fSECTION 1 - SITE INFORMATION
Property Address This section to be completed by office
Map Lot Unit
J' Zone
Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner o cord:
Name (Print) Current 4Mail' U lT
Telephone
Signature
2.2 Authorized A en
Name (Pr t) ui nt Mailing Addres - Y?
9 �
�► (�`�
Sin Telephone w
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit a licant
1. Building .— �--� (a) Building Permit Fee
2 FlPrtriral
(b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) r Check Number
This Section For Official Use Onl
[Building Permit Number: Date
Issued:
ature: 0 7A 7– /CI0
Building Commissioner /Inspector of Buildings
Date
• S
1 4
Y
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L .. . R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage °
/o
(Lot area minus bldg & paved
p arking)
# of Parking S aces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:'.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page, and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable
New House ❑ Addition Replacement Wi ws Alteration(s) Roofing E7 Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [M Siding [a] Other [0]
Brief Description of Proposed �
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition t existing housing complete the followin
a. Use of building : One Family J Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT -
1' as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, R I A, t as Owner /Authorized
Agent hereby declare Mat t statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the and pens f perjury.
" p ,
Print ame
r
ture o caner /A n Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction §=@"isor Not Applicable ❑
Name of License Holder
Licens4 UnTgr
z"'N J?� Chi 7 -
Addr s Expiration Dat
3
I ( Siaizur 1 Telephone
r�
9. Registered Nome Im Contractor: Not Applicable ❑
Company Name Registration Num er
awl
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building pwrnit.
Signed Affidavit Attached Yes....... No...... ❑
11. Horne Owner Exemption'
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official that he /she shall be
responsible for all such work performed under the buildine permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting, in Death) of the Massachusetts General Lnwo Annotated, you may be liable fui pn sun(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he /she resides or intends to be, a one or two family
dwelling, attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two -year period shall not be considered a
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill,
sonotube holes (before your), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Tate
Address of work
location
Y
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 ff'ashington Street
Boston, MA 02111
�. www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
i. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. F New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
have ave
ship and have no employees These sub-contractors 8. ❑Demolition
working for me in any capacity. ernployccs and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. F Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site
information.
Insurance Company Name: _
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City /State /Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of uh to $250 00 a clay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverag verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone #:
Of use only. Do not write in this area, to be completed by cioJ or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
sold Furnisbed and Installed by:'.
Brunch Name: Vestow . Date: d THO- At..Home 5 ' " ota. :lna
dib�a . FhcYas�ee,1?eDet ome Sctvicea. , .
43A Cnxnwoad StizeA.unit'7, Worcestr r; MA 01407
Br:tacb NPmbEr. 3 t ToH p'ree {800} 667 5182;,, Pax 008)'7564$23.
1 edetal 1f3 :# f5 2b9841SQ; 2d1 Lie # C p2�k3ii 'RE Cart .CSC# IG427
�:T' IaG #365522; ='M�k f�a�e TnipYovemeat Gan6aator lCeg.'# I2b8�3
Installation Address: b= Jn 5 T t__{ � � � � � � �•
LAY_ 51AW Zip 1 .
Purchaser(a) k Phone:: me CaII Yhom: ��L "�►^
[.. 7: [: .. 7 .:. [ .. .
Rome Address:
(If different tram is gluation Ad&esi) City State
E-mail Addreos {to•receive project Qomnnmications and Home Depot updates):
❑ l'Do )7OT wish to tcccivc say muicetine as iiotrl :Tbc ?40=
Pr t ar il�ti0lt t', Undersigned (( "Customer }, the owners of the ooppe��rtyy Iol�ed.o�llre aiiatite iastallatioi}addncas.'aSrxa to brut, .
At - Florae services, Inc. {'"i he Rome' Depot agpeed to farm !r'delww taxi *for the iaataLatidn {'Taganatti") of
aU materials described on the below and on the referetictil Spec sett ee{sj, s}l of 'vrhic)i fit :ineorpotnied i%ltp this Go', ti this
a��it .
reibrcnec. along with ariy applrcable State supplenaem W Payment'Stunwa Y "
' I ,- !Fero agd,any Chersge abUe vely,
job #: tw+aw a ha ) 1? redtreta: S Sh # A1nai+aE :
Roofing OSidarg WiodP - : u Immolation'
QGutters / Covers spots 0
- Roofing siding Windovis brsutatiatt .
OGutbm / Caves ❑$ntry Sloss Cl,. ,.
Roofing OSidint 0 Windows 0 AMJAu0-
❑4u[tets / Covers []Entry Doors ( L
R00fing omits ❑ vr%& rs 0 in% $
0CMU a ! Covers ❑1E atv Dom
1►fy mj59sY> rpoaCtotConrraaAmevtn due
apoa .aategG?nolt rafiikCe raattnr S ;' yyrr�
Mohm riarchows may not deposit more diap oseahird ofebe (oatraa.lurroant T.d
C ucromer agrees that, irmnedistely upon cQtw0lat16n i}f:rhe wLn&Ilbir, baclr :Prl d,- t*4 F' ?• :� e'h Cgipp £sate
ne for oarh.Aroductas defindd.by am: rtidvidtia l : apab a tntder this
(o
Contract agrctsio'.bc jomtlysrnd aev�eiakljrob {i>�'�#l'gii8'l>R�e.��' = �•��r;, ''�.t , ..
The Home Depot rescrvcs the' rigbt'to iasne h Ch2' pe+Ordea. Qr xfatC Cb?.s Ci ofitraCt 4� ,�j ija}j j s)irtcloded herein, at
its discretion, if The dome Depot or its 6ith arized. soviet: grovid4x tiCtcrmine €,tits itoaetabtpEifortri its pfsligtitiotas diu fo'a tttrtlCbkEt
problem with the home, environments% hazards such as'mald,,aabGstO's or" lead''par if ot}ier'salCfy Concems. pricing ac ors or beauw
work required to toinpleto the job was not incloatd'in the contract.
PA at.5 mmarv: The Payment Summary mdUdtd `as part of Ibis Contract, sets ,forth.lha % 01211
Contract amount aud.paymom required for the deposits and-final payments by Product fns towlicabie).
TYOTICE.T otuSTOM
You are entitled to a completely f ued4a copy of the coiltract at. thekme you. Sim Do4or'sip"a Compir ipu Cat (note:
there is one Completion Certificate for each listed Product." deffned'b* *Oyidllt�•S*:Sheets) befaitworkon that Product
is covaplete.
In the aveet of termination of this Contract, Coatom agrees to pay Tho.admv Ds of tb* awtt of rnatertaiN labor, ertpeoses
and services provided by The Home A or AuthorUtd Service PrOVMW tliMUW the date Ot ter0l"tlon, lus other
¢mount# set forth in this Agreement or alMwed under app1itable last. TIM VIONI DEPOT MAY .LN"
OWED TO TIDE HOME DEPOT FROM THE DEPOSIT PAYMENT OR OTRER. PAYMENTS MADE, WITHOUT
LThCITTN'ty 'I U e ritOMTi DHYOT'S OTH F.R 'R'EMEDIES FOR RECOVEItY OF 90CH AMOUNTS.
Aeceotance and_AUtborliudon Customer agrees and tmderstaads that this A� is the entire agreement between Customer
and Home Depot with regard to rlre Producra and Imtallatian services and $0P4V&& all prior discussions and agroeme % either
oral or written. relating to said PmdwU and Installation. This Ngteement cannot be assigned or amended except by a writing signed
byp4slowncrand The Hoene Depot Gwte war aelmowledges and agrooe that Customer bas read, understands, vohaztuily aeeepts the
e f
A and has tc vcd a copy of this Agreen*4tT.
t bye P Bubuti
A(Z _ __�
Custo s Si Hate Salta/ nt's Si Dam
Telephone No. -- -
Customer's Signature Date Sales Consultant License No.
C�ANC9L.L.ATION CUSTOMER MAY CANCEL THIS (
AGREEMENT WITHOUT PENALTY OR OlIUCATION
BY DELIVERING WRIJ' N NOTICE. TO TIM HOME
DEPOT I;Y' MIDNTtyRT ON TIM THIRD BUSINESS
DAY AFTER SIGNING THIS AGrREEb1E". THE
STATE SUIPPLEIitOENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONE IS
S?ECI"CALLY PRE$GRIBE;D BY LAW IN
CUSTOMER'S STATE.
NOT ICE: APDITtONAL TERMS AND COND11 A14E STATED ON TWOS REV== SD]E AND AM PART OS' THIS CONTOACr
6.809 C -3C White - ®ranch File Yoikw- Cuetomar. Pink. SatesConauaani
The Commonwealth of Massachusetts
Department of Industrial Accidents
)? Office of Investigations
600 l'Vashingtorl Street
Boston, MA 02711
wrvw.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legib
Name ( Business /Organization/Individual): r--
Address: �4 J ka
City /State /Zip: C �-} �� �., )D335 Phone. #:
APlo-am yo an employer? Check the appropriate bog: . Type of project (required):,
1. a employer with 4. ❑ I am a general contractor and I
employees (full and/or part - time ).
* have hired the sub- contractors 6. New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet_ 7. ❑ Remodeling
shi p e and have no em to ees These sub - contractors have g
_
working for me in any capacity. empl . E] Demolition and have workers' 9 E] Building addition
[No workers' comp. insurance comp. insurance.t
required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof re s
insurance required.) t c. 152, § 1(4), and we have no
employees. [No workers' 13.el Other
comp. insurance required.)
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
( Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy andjob site
information.
Insurance Company Name:
Policy # or Self -ins. Lie. #: Expiration �j� Expiration Date:
Job Site Address: t City/State /Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiratiop date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine tip to $1,5.00.00 and/or one -year i m p r i s o n m e n t R� and a ftne
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi un r e p s an penalties of perjury that the information provided above is true and correct.
Si ature:
- Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town offteiaL
City or Town: Pertnit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Depaillnellt of Public �afct
�
Board of BuHdiw- Regulations and Standm-(Is
... ,:F r i a - ; � . �
�l—"-'Ho" -
License: CS SL 98785
Restricted to: WS
IVAN KOSOBUTSKYY
72 STAFFORD ROAD
MONSON, MA 01057
Expiration: 4127/2012
Tr--: 98785
Ile 1C